Healthcare Provider Details

I. General information

NPI: 1710923750
Provider Name (Legal Business Name): MINESH MEHTA M.D., C.C.F.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 E CARSON ST SUITE 104
CARSON CA
90745-2262
US

IV. Provider business mailing address

824 E CARSON ST SUITE 104
CARSON CA
90745-2262
US

V. Phone/Fax

Practice location:
  • Phone: 310-793-3520
  • Fax: 310-830-6621
Mailing address:
  • Phone: 310-793-3520
  • Fax: 310-830-6621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA062994
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: